Annals for Hospitalists - July 2023
Authors: David A. Fried
Journal: Annals of Internal Medicine (2023)

Web ExclusivesJuly 2023Annals for Hospitalists - July 2023FREEDavid A. Fried, MDDavid A. Fried, MDFrom University of Michigan, Ann Arbor, Michigan (D.A.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202307180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Highlights of Recent Articles From Annals of Internal MedicineIn the Clinic: Atrial FibrillationAnn Intern Med. 2023;176: ITC97-ITC112. Published 11 July 2023. doi:10.7326/AITC202307180This article provides a narrative review of the current evidence regarding diagnosis and treatment of atrial fibrillation.Key points for hospitalists include:Although atrial fibrillation is often asymptomatic, patients who present with palpitations, dyspnea, or other concerning symptoms should have an electrocardiogram. If the electrocardiogram does not show atrial fibrillation, but clinical suspicion for paroxysmal disease remains high, longer duration monitoring can be pursued. Consumer wearable technology can also diagnose atrial fibrillation, but the accuracy is unclear.The author recommends the following initial testing in all patients with a new diagnosis of atrial fibrillation: serum electrolytes and thyroid stimulation hormone levels (for cause), renal and hepatic function (to guide drug therapy), complete blood count and stool heme occult (before starting anticoagulation), and transthoracic echocardiogram (to evaluate for underlying structural heart disease and cardiomyopathy).Newer studies show that early rhythm control within 1 year of diagnosis reduces the risk for the composite outcome of death due to cardiovascular causes, stroke, and hospitalization for decompensated heart failure or acute coronary syndrome. Rhythm control can be achieved by cardioversion, catheter ablation, or antiarrhythmic drugs. Catheter ablation is associated with a larger improvement in quality of life compared with antiarrhythmic drugs.To prevent thromboembolism, anticoagulation should be considered in all patients with atrial fibrillation, regardless of whether paroxysmal or undergoing rhythm control. Barring the presence of significant bleeding risks, a patient with 2 or more CHA2DS2-VASc risk factors should receive anticoagulation. Guidelines now recommend non–vitamin K–dependent oral anticoagulants as first-line treatment in all patients aside from those with mitral stenosis or mechanical valves.Left atrial appendage occlusion devices are now available to reduce the risk for stroke in patients with atrial fibrillation. They are appropriate for patients who have higher bleeding risks or who do not want to take an anticoagulant indefinitely. Of note, most patients still require 45 days of anticoagulation plus aspirin after the procedure followed by up to 6 months of dual antiplatelet therapy and then indefinite aspirin therapy.Indefinite Anticoagulant Therapy for First Unprovoked Venous Thromboembolism: A Cost-Effectiveness StudyAnn Intern Med. 2023;176:949-960. Published 27 June 2023. doi:10.7326/M22-3559This modeling study evaluated the clinical outcomes and costs of indefinite anticoagulation with direct oral anticoagulants in patients experiencing their first unprovoked venous thromboembolism (VTE) as compared with treating for 3 to 6 months. The data used to create the model came from recently published systematic reviews and meta-analyses about rates of recurrent VTE, major bleeding, death, and other complications related to the treatment of unprovoked VTE. The cost analysis was done from the perspective of the Canadian public health care payor. In a hypothetical cohort of 1000 patients (all aged 55 years), the model indicated that indefinite anticoagulation prevented 368 recurrent VTE events and 14 fatal pulmonary embolism events and caused 114 major bleeding events, which included 30 intracranial bleeds, and 11 fatal bleeds. Indefinite anticoagulation increased lifetime costs by CAD $16 014 per person and was not associated with an increase in quality-adjusted life-years. A subgroup analysis did find that indefinite anticoagulation in patients who presented with pulmonary embolism rather than deep venous thrombosis had an 80% probability of providing improvements in quality-adjusted life-years (providing an average increase of 49 days of perfect health) but only a 24% probability of being cost-effective in doing so.Key points for hospitalists include:This study found that indefinite anticoagulation for a first unprovoked VTE is unlikely to reduce mortality despite a 3:1 ratio of prevented VTE to major bleeding events. This is due to the higher case-fatality rate of bleeding events.Without leading to any improvement in quality-adjusted life-years, indefinite anticoagulation was not cost-effective.The study did not differentiate between upper extremity or lower extremity deep venous thrombosis or distal versus proximal deep venous thrombosis, which all have different risks for future morbidity. In addition, the model did not include younger patients who likely have lower bleeding risk profiles.The authors recommend that future research focus on developing prediction tools to identify which patients have a lower risk for bleeding because they are more likely to benefit from indefinite anticoagulation. They also suggest a role for shared decision making, as some patients may prioritize the 3-fold prevention of VTE over the increased risk for severe bleeding.Clinical Characteristics and Outcomes Among Travelers With Severe Dengue: A GeoSentinel AnalysisAnn Intern Med. 2023;176:940-948. Published 20 June 2023. doi:10.7326/M23-0721In the largest case series to date, this study describes the epidemiology, clinical signs and symptoms, and outcomes of complicated dengue related to international travel. The authors defined complicated dengue as a combination of the “dengue with warning signs” and “severe dengue” categories from the 2009 World Health Organization guidelines. The case series included 5958 patients with dengue, 95 (2%) of whom had complicated disease. More than half of the patients contracted dengue in the Caribbean and Southeast Asia. Of the patients with complicated disease, 91% required hospitalization with a 5-day median length of stay. Seventeen percent of hospitalizations included intensive care unit admission. Patients with comorbidities were more likely to require intensive care unit–level care. The only death was due to nondengue–related disease. The most common presenting signs and symptoms of complicated disease included thrombocytopenia (78%), elevated aminotransferase (62%), bleeding (52%), and plasma leakage (20%). Among the complicated cases classified as severe, the most common organ involvement included severe liver disease, eye disease, myocarditis, and neurologic symptoms.Key points for hospitalists include:Dengue is a widely occurring arboviral infection with 50 to 100 million cases reported annually, leading to more than 40 000 deaths each year.Although quite rare in travelers returning from endemic countries, complicated disease typically requires hospitalization. Warning signs for severe disease include abdominal pain, intractable vomiting, hepatomegaly, mucosal bleeding, and plasma leakage (effusions and ascites). Severe disease is defined as dengue associated with shock, respiratory failure, organ failure, or severe hemorrhage.Supportive care during hospitalization greatly reduces the risk for death. Therefore, the authors recommend hospital admission for patients with dengue and warning signs, especially those with comorbidities, in order to monitor for progression to severe disease.Because of the retrospective chart review nature of the study, it is at risk for misclassification and reporting bias, leading to an underestimation of complicated dengue rates.The Latest Highlights From Journal ClubDoes a shorter period of dual antiplatelet therapy after percutaneous coronary intervention lead to worse outcomes?P2Y12 inhibitor monotherapy 1 to 3 mo after PCI did not differ from standard DAPT for fatal or ischemic eventsAnn Intern Med. 2023;176:JC66. doi:10.7326/J23-0032This meta-analysis of 5 randomized controlled trials (n = 22 941) showed that P2Y12 inhibitor monotherapy following 1 to 3 months of dual antiplatelet therapy after percutaneous coronary intervention led to a decrease in major bleeding events without increasing mortality or ischemic events when compared with the standard 6 to 12 months of dual antiplatelet therapy.Is endovascular thrombectomy safe and effective in patients with large ischemic-core volume strokes?In large acute ischemic stroke, adding endovascular thrombectomy to medical therapy improved function at 90 dAnn Intern Med. 2023;176:JC65. doi:10.7326/J23-0033This randomized controlled trial (n = 352) of patients who had ischemic strokes with large ischemic-core volumes on imaging found that endovascular thrombectomy within 24 hours of symptom onset, when added to usual medical therapy (including thrombolysis), improved functional outcomes at 90 days (odds ratio for improvement in modified Rankin score was 1.51 [95% CI, 1.20 to 1.89]).How does tricuspid transcatheter repair compare with medical therapy alone in patients with severe tricuspid regurgitation?In severe tricuspid regurgitation, tricuspid TEER improved QoL more than medical therapy at 1 yAnn Intern Med. 2023;176:JC67. doi:10.7326/J23-0037This randomized controlled trial (n = 350) of adults with severe tricuspid regurgitation found that transcatheter repair led to an improvement in quality of life after 1 year when compared with medical therapy alone (number needed to treat of 5) without decreasing mortality or heart failure hospitalizations.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David A. Fried, MDAffiliations: From University of Michigan, Ann Arbor, Michigan (D.A.F.)Disclosures:The author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics July 2023Volume 176, Issue 7 ePublished: 18 July 2023 Issue Published: July 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...